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1 • ! <br /> 1 <br /> i <br /> SUPERVISOR'S ACCIDENT INVESTIGATION <br /> 1 (To be completed by employee's supervisor or other responsible administrative official) <br /> 1 Location where accident occurred Employer's premises: Y❑ N❑ Date of accident or illness <br /> Jobsite: Y❑ N❑ <br /> Who was injured? ❑ Employee Time of accident AM ❑ <br /> ❑ Non-employee I PM ❑ <br /> 1 Length of time with firm Job title or occupation Dept.normally assigned to How long has employee worked at job <br /> where injury or illness occurred? <br /> 1 What property/equipment was damaged? Property/equipment owned by: <br /> What was employee doing when injury/illness occurred?What machine or tool was being used?What type of operation? <br /> 1 <br /> 1 How did injury/illness occur?List all objects and substances involved. <br /> 1 <br /> 1 <br /> 1 Part(s)of body affected/injured? Any prior physical conditions?If so,what? <br /> Y ❑ N ❑ <br /> Nature and extent of injury/illness and property damaged(be specific) <br /> 1 <br /> Supervisor's corrective action to ensure this type of accident does not recur: <br /> 1 <br /> 1 Was employee trained in appropriate use of personal protective equipment/proper safety procedures?.................... Y❑ N❑ <br /> 1 Was employee cautioned for failure to use personal protective equipment/proper safety procedures?...................... Y❑ N❑ <br /> Did employee promptly report the injury/illness?...................................................................................................... Y❑ N❑ <br /> Isthere modified duty available?................................................................................................................................ Y❑ N❑ <br /> 1 <br /> 1 Ami Adini <br /> &Associatos,lnc. <br /> 1 <br />